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HomeMy WebLinkAbout1085A 1086A (5) WORKERS'COMPENSATION DECLARATION � insureboraafcerlifca'te of Wo kersrrCompe�sofion Insuran ef APPLICATiON FOR BUILDING PERMIT or a certified copy thereof(Sec 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olicy No. G 1���un m,vu/�/���mpany IIAILTFORD GROUP � BUILDING CertiFied copy is hereby fumished. FOR APPLICANT TO FILL IN ADDRE55 � � ���+^^�" '� ' � Certified copy is filed with the counfy building insper BUiLoinlG ,k X tion cleparimeM. ADDRESS 1458 S. VALEVIEW DR. �aA��TY �1/����• NEAREST Date Applimnt CITY DIA:40ND EAR ZIP CRO555T. ERTIF CATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE 51ZE OF LOT NOW ON LO7 — MAP 800K PAGE PARCEL (This section need not be completed if the permii is for one USE ZONE MAP �. hundred dollars($100)or less.) TRAcr 42554 6LOCK iot No. 5 �(�� rvo. ��- �"'`� TEL. SPECIAL � I certify that in the performance of the work for which this owNee BRAMALEA LI.T�II`LED NO. _ ++`�Od f)O COND�T�ONS �- DISTRICT GROUP iYPE FIRE PROCESSED BY �} permit is issued,I shall not employ any person in any manner ���,,,yyy k2 so as ro become subject io ihe Workers'Compensation Laws. AooRe553151 AIRWAY AVE. SUITE N � 3 co� zo U � arr COSTA MESA CA. ziN 9 `U '��` Dafe Applicant STATISTICAL C1A551FICATION APT. NDO. �^^ ARCHI7EQ OR TEL �.f ��7TICE TO APPLICANT: If, after making ihis Certificate of �"� j' sxr ption, you sho�ld become sobieci ro �he worke.s' E"�iNEER NdS2-1864 anss No. oweu.uNirs � :�pensafion provisions of the labor Code,you must forlh- qDDRE55 SEWER MAP � with comply "th such provisions or this permit shall be � ' '� deemed revoked. COrvTRACTOR b'RA�'�LEA Cf�ir NO.$ —1001 BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION .uC. i hereby affirm thot I am licensed under provizions of Chapfer 9 ADDRE55 NO. VAlUAT10N (commencing with Section 7000)of Division 3 of the Business and uc. Professions Code,and my license is in foll torce a�d effec�. ci�o�STA MESA� CA. 92626 c�ass B `+ f y Q�O� , Sq.FT. NO OF NO.OF CHECK s� O�+�'Fl LicenseNum6er 409610 �;c.cioss BT size 2144 sTORies 2 FnnnwEs 1 oNe BRAMALEA CALIT ,, � ��� $ � n 6 0 Q c 1 Contracfor Date_�2��� DESCRIP710N OF WORK Z�F C1Z. NEW � ❑!am exempt under Sec. I LY RESIDENCE ADO � � I �y C�J�6 i A�TER � FINAL n o�:Ll";�C cSi NEW CONSTRUCTION � OATE ���.3 ,�� B.BP.C.for this reason REPAIR G 7:0 2—8 b Dqte' � E%STOINGBL�G. NE �EMOL ❑ BYAL ��� Signature APPUCANT TE OWNER-BUILDER DECLARATION PRINT BF.UCE L. ABEEY NO. —LOOL I hereby affirm that I am exempt from the Contra nse qooaesS 1 1 AIRWAY AVL. N COSTA PSES�Z�A. , '�� G L�p Law for fhe following reason�Section 7031.5, siness nd Professions Code): � • » • . « � 6UILDING �� I, as owner of Ihe property, or my employeas wiih ADDRE55 , wages ds iheir sole tompensation,will do the work and LOCAL�TY + ����U G the structure is noi intended or offered for sale(Section 7044,Business ond Professions Code). MOviNG TEL g ,+��}�,(}�J� � I,as owner af the property,am exciusively conirocting CONTRACTOR N0, o with licensed coMractors to construct the project(Sec- �qDDRE55 �7�O�"�V v tion 7044,Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. WNSTRUCTION LENDING AGENCV Sei sACK vnRD HWv pROP.LINE wioiH , I here6y affirm thai ihere is o consiruction lending agency for FRONT � �he performance of ihe work for which this permit is issued P.L � (Sec.3097,Civ.C.). - SIDE Lendei s Name TORONTO DOMINION BANK P'�' $ 11�+ SANSOAfE 5T. SUITE p_C.fee$ °-��3-(� 'L Permit Fee �J`�7• '�(, y Lender's Addres$�,1T FRANCTCC(1� ea_ 941�4 �Q �� I certify ihat I have read ihis application and state ihat the Issu ce Fee ¢ above information is correci.I agrae to comply with all County Investigation Fee �n �p�r Q � , � ordinances and State laws relating to building construction, Total Fee 0 � and hereby authorize representatives of this County to enter � upon the above-mentioned property for inspection pur ses. 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